Case 2

A 59-year-old woman attends the ED complaining of left sided chest pain. The pain started suddenly today whilst she was eating her breakfast. Three weeks ago she fell down a short flight of stairs and sustained a fracture to her left ankle. The fracture was treated by internal fixation and cast immobilisation. She is otherwise previously fit and well.

On examination, she appears to be overweight but looks well. She has some chest wall tenderness on the left but the pain is not worse on movement. Her chest examination is otherwise normal. She denies shortness of breath but her pain is worse on deep inspiration.

Her observations are as follows:

• Pulse 98 bpm
• BP 137/76
• RR 20
• SpO₂ of 95% on room air
• Temperature 37.3 °C

An ECG shows no abnormalities and an erect PA chest radiograph appears normal.

Risk stratify this patient with regards to risk of having a PE (no risk, low risk (PE unlikely), or high risk (PE likely)) and in the free text box below list an appropriate investigation strategy for excluding a PE in this patient:

Two days after attending the ED the patient is on a medical ward awaiting her discharge medications, which include warfarin. She suddenly collapses to the floor and is found to be hypotensive (BP 60/35) and bradycardic (pulse 56 bpm) with a very weak pulse. She is unconscious and agonal breathing. The 'Crash Team' is called.

Which of the following immediate management options should be considered in this case? 

Select one or more options.